<div>
<div style="width:800px;height:1030px;background-color: #EEEEEE; font-size:6px">
	<div class="head">
		<div style="float:left;height:100%;width:80px;border:1px solid black">IMAGE</div>
		<div style="float:left;height:100%;width:463px;">
			<span style="font-size:25px; font-weight:bold;">Occupant / Witness Addendum</span>
			<hr style="position:relative; bottom:6px;" size="3px" color="black">
		</div>
		<div style="float:left;border:1px solid black;height:100%;width:253px;">
			<span class="top">Local Report Number</span>
			<table class="bottom">
				<tr>
					<td class="inside"></td>
					<td class="inside"></td>
					<td class="inside"></td>
					<td class="inside"></td>
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					<td class="inside"></td>
					<td class="inside"></td>
					<td class="inside"></td>
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				</tr>
			</table>
		</div>
	</div>
	<div class="row">
		<div style="width:70px;height:100%;border-right:1px solid black;float:left">
			<span class="top">Unit number</span>
			<table class="bottom">
				<tr>
					<td class="inside">A</td>
					<td class="inside">B</td>
				</tr>
			</table>
		</div>
		<div style="width:400px;height:100%;border-right:1px solid black;float:left">
			<span class="top">Name: Last,First,Midle</span>
		</div>
		<div style="width:140px;height:100%;border-right:1px solid black;float:left">
			<span class="top">Date of Birth</span>
			<table class="bottom">
				<tr>
					<td class="inside"></td>
					<td class="inside"></td>	
					<td class="inside"></td>
					<td class="inside"></td>
					<td class="inside"></td>
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					<td class="inside"></td>
					<td class="inside"></td>
				</tr>
			</table>
		</div>
		<div style="width:60px;height:100%;border-right:1px solid black;float:left">
			<span class="top">Age</span>
		</div>
		<div style="width:120px;height:100%;float:left">
			<span class="top">Gender</span>
				<div class="box-large">
					F
				</div>
				<div class="next-box"><pre>
					F - Female
					M - Male</pre>
				</div>
		</div>
	</div>
	<div class="row">
		<div style="float:left;border-right:1px solid black;height:100%;width:500px;">
				<span class="top">Address,City,State,Zip</span>
		</div>
		<div style="float:left;height:100%;width:298px;">
			<span class="top">Contact Phone-include area code</span>
		</div>
	</div>
	<div class="row">
		<div style="float:left;border-right:1px solid black;height:100%; width:40px">
			<span class="top">Injuries</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:70px">
			<span class="top">Injured Taken By</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:150px">
			<span class="top">EMS Agency</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:150px">
			<span class="top">Medical Facility Injured Taken To</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:100px">
			<span class="top">Safety Equipment Used</span>
			<div class="couple-box">
				<div class="box-inside">A</div>
				<div class="box-inside" id="right">B</div>
			</div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:60px">
			<span class="top">DOT Compliant Motorcycle Helmet</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:80px">
			<span class="top">Seating Position</span>
			<div class="couple-box">
				<div class="box-inside">A</div>
				<div class="box-inside" id="right">B</div>
			</div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:60px">
			<span class="top">Air Bag Usage</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:40px">
			<span class="top">Ejection</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;height:100%; width:40px">
			<span class="top">Trapped</span>
			<div class="box-large"></div>
		</div>
	</div>
	<div class="row">
		<div style="float:left;border-right:1px solid black;height:100%; width:50px">
			<span class="top">OL State</span>
			<table class="bottom">
				<tr>
					<td class="inside"></td>
					<td class="inside"></td>
				</tr>
			</table>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:140px">
			<span class="top">Operator License Number</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:40px">
			<span class="top">OL Class</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:40px">
			<span class="top">No Valid OL</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:40px">
			<span class="top">M/C End</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:40px">
			<span class="top">Condition</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:100px">
			<span class="top">Alcohol/Drug Suspected</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:70px">
			<span class="top">Alcohol Test Status</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:68px">
			<span class="top">Alcohol Test Type</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:80px">
			<span class="top">Alcohol Test Value</span>
			<table class="bottom">
				<tr>
					<td class="inside"></td>
					<td class="inside"></td>
					<td class="inside"></td>
				</tr>
			</table>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:60px">
			<span class="top">Drug Test Status</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;height:100%; width:60px">
			<span class="top">Drug Test Type</span>
			<div class="box-large"></div>
		</div>
	</div>
	<div class="row">
		<div style="float:left;border-right:1px solid black;height:100%; width:220px">
			<span class="top">Offense Charged ( Local Code)</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:215px">
			<span class="top">Offense Description</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:200px">
			<span class="top">Citation Number</span>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%; width:70px">
			<span class="top">Hands-Free Device Used</span>
		</div>
		<div style="float:left;height:100%; width:30px">
			<span class="top">Driver</span>
			<div class="box-large"></div>
		</div>
		<div style="float:left;height:100%; width:40px">
			<span class="top">Distracted By</span>			
			<div class="box-large"></div>
		</div>
	</div>
	<div class="row-large">		
		<div style="float:left;border-right:1px solid black;height:100%;width:120px;">
			<dl>
				<dt>Injuries</dt>
				<dd>1 - No Injury / None Reported</dd>
				<dd>2 - Possible</dd>
				<dd>3 - Non-Incapacitating</dd>
				<dd>4 - Incapacitating</dd>
				<dd>5 - Fatal</dd>
			</dl>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%;width:114px;">
				<dl>
				<dt>Injured Taken By</dt>
				<dd>1 - Not Transported / Treated at Scene</dd>
				<dd>2 - EMS</dd>
				<dd>3 - Police</dd>
				<dd>4 - Other</dd>
				<dd>9 - Unknown</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:140px;">
				<dl>
				<dt>Safety Equipment Used Motorist</dt>
				<dd>01 - None Used - Vehicle Occupant</dd>
				<dd>02 - Shoulder Belt Only Used</dd>
				<dd>03 - Lap Belt Only Used</dd>
				<dd>04 - Shoulder and Lap Belt Used</dd>
				<dd></dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:140px;">
				<dl>
				<dt></dt>
				<dd>99 - Unknown Safety Equipment</dd>
				<dd>&nbsp</dd>
				<dd>05 - Child Restraint System-Forward Facing</dd>
				<dd>06 - Child Restraint System- Rear Facing</dd>
				<dd>07 - Booster Seat</dd>
				<dd>08 - Helmet Used</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:140px;">
				<dl>
				<dt>Non-Motorist</dt>
				<dd>09 - None Used</dd>
				<dd>10 - Helmet Used</dd>
				<dd>11 - Protective Pads Used (Elbows,Knees, Etc)</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:140px;">
				<dl>
				<dt>&nbsp</dt>
				<dd>12 - Reflective Clothing</dd>
				<dd>13 - Lighting
				<dd>14 - Other</dd>
			</dl>
		</div>
	</div>
	<div class="row-large">		
		<div style="float:left;height:100%;width:220px;">
			<dl>
				<dt>Seating Position</dt>
				<dd>01 - Front - Left Side (Motorcycle Driver)</dd>
				<dd>02 - Front - Middle</dd>
				<dd>03 - Front - Right Side</dd>
				<dd>04 - Second - Left Side (Motorcycle Passenger)</dd>
				<dd>05 - Second - Middle</dd>
				<dd>06 - Second Right Side</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:220px;">
			<dl>
				<dd>&nbsp</dd>
				<dd>07 - Third - Left Side (Motorcycle Side Car)</dd>
				<dd>08 - Third - Middle</dd>
				<dd>09 - Third - Right Side</dd>
				<dd>10 - Sleeper Section of Cab (Truck)</dd>
				<dd>11 - Passenger in Other Enclosed Cargo Area (Non-Trailing Unit Such as a Bus, Pick-up with Cap)</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:205px;border-right:1px solid black">
			<dl>
				<dd>&nbsp</dd>
				<dd>12 - Passenger in Unenclosed Cargo Area</dd>
				<dd>13 - Trailing Unit</dd>
				<dd>14 - Riding on Vehicle Exterior (Non-Trailing Unit)</dd>
				<dd>15 - Non-Motorist</dd>
				<dd>16 - Other</dd>
				<dd>99 - Unknown</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:150px;">
			<dl>
				<dt>Air Bag Usage</dt>
				<dd>1 - Not Deployed</dd>
				<dd>2 - Deployed Front</dd>
				<dd>3 - Deployed Side</dd>
				<dd>4 - Deployed Both Front/Side</dd>
				<dd>5 - Not Applicable</dd>
				<dd>9 - Deployment Unknown</dd>
			</dl>
		</div>		
	</div>
	<div class="row-large">		
		<div style="float:left;border-right:1px solid black;height:100%;width:100px;">
			<dl>
				<dt>Ejection</dt>
				<dd>1 - Not Ejected</dd>
				<dd>2 - Totally Ejected</dd>
				<dd>3 - Partially Ejected</dd>
				<dd>4 - Not Applicable</dd>
			</dl>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%;width:120px;">
			<dl>
				<dt>Trapped</dt>
				<dd>1 - Not Trapped</dd>
				<dd>2 - Extricated by</dd>
				<dd> Mechanical Means</dd>
				<dd>3 - Extricated by Non-Mechanical Means</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:120px;border-right:1px solid black	">
			<dl>
				<dt>Operator License Class</dt>
				<dd>1 - Class A</dd>
				<dd>2 - Class B</dd>
				<dd>3 - Class C</dd>
				<dd>4 - Regular Class (Ohio is “D”)</dd>
				<dd>5 - MC/Moped Only</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:151px;">
			<dl>
				<dt>Condition</dt>
				<dd>1 - Apparently Normal</dd>
				<dd>2 - Physical Impairment</dd>
				<dd>3 - Emotional (Depressed, Angry, Disturbed)</dd>
				<dd>4 - Illness</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:151px;border-right:1px solid black">
			<dl>
				<dt>&nbsp</dt>
				<dd>5 - Fell Asleep, Fainted, Fatigued</dd>
				<dd>6 - Under The Influence of Medications, Drugs, Alcohol</dd>
				<dd>7 - Other</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:140px;">
			<dl>
				<dt>Alcohol/Drug Suspected</dt>
				<dd>1 - None</dd>
				<dd>2 - Yes - Alcohol Suspected</dd>
				<dd>3 - Yes - HBD Not Impaired</dd>
				<dd>4 - Yes - Drugs Suspected</dd>
				<dd>5 - Yes - Alcohol and Drugs Suspected</dd>
			</dl>
		</div>			
	</div>
	<div class="row-large">		
		<div style="float:left;border-right:1px solid black;height:100%;width:200px;">
			<dl>
				<dt>Alcohol Test Status</dt>
				<dd>1 - None Given</dd>
				<dd>2 - Test Refused</dd>
				<dd>3 - Test Given, Contaminated Sample/Unusable</dd>
				<dd>4 - Test Given, Results Known</dd>
				<dd>5 - Test Given, Results Unknown</dd>
			</dl>
		</div>
		<div style="float:left;border-right:1px solid black;height:100%;width:80px;">
			<dl>
				<dt>Alcohol Test Type</dt>
				<dd>1 - None</dd>
				<dd>2 - Blood</dd>
				<dd>3 - Urine</dd>
				<dd>4 - Breath</dd>
				<dd>5 - Other</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:150px;border-right:1px solid black">
			<dl>
				<dt>Drug Test Status</dt>
				<dd>1 - None Given</dd>
				<dd>2 - Test Refused</dd>
				<dd>3 - Test Given, Contaminated Sample/Unusable</dd>
				<dd>4 - Test Given, Results Known</dd>
				<dd>5 - Test Given, Results Unknown</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:80px;border-right:1px solid black">
			<dl>
				<dt>Drug Test Type</dt>
				<dd>1 - None</dd>
				<dd>2 - Blood</dd>
				<dd>3 - Urine</dd>
				<dd>4 - Other</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:131px;">
			<dl>
				<dt>Driver Distracted By</dt>
				<dd>1 - No Distraction Reported</dd>
				<dd>2 - Phone</dd>
				<dd>3 - Texting/E-mailing</dd>
				<dd>4 - Electronic Communication Device</dd>
				<dd>5 - Other Electronic Device (Navigation Device, Radio, DVD)</dd>
			</dl>
		</div>
		<div style="float:left;height:100%;width:140px;">
			<dl>
				<dt>&nbsp</dt>
				<dd>6 - Other Inside the Vehicle</dd>
				<dd>7 - External Distraction</dd>
			</dl>
		</div>
	</div>

</div>
<div>